An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients

OBJECTIVE: To determine whether early enteral feeding in a septic intensive care unit (ICU) population, using a formula supplemented with arginine, mRNA, and omega-3 fatty acids from fish oil (Impact), improves clinical outcomes, when compared with a common use, high protein enteral feed without these nutrients. DESIGN: A prospective, randomized, multicentered trial. SETTING: ICUs of six hospitals in Spain. PATIENTS: One hundred eighty-one septic patients (122 males, 59 females) presenting for enteral nutrition in an ICU. INTERVENTIONS: Septic ICU patients with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of > or =10 received either an enteral feed enriched with arginine, mRNA, and omega-3 fatty acids from fish oil (Impact), or a common use, high protein control feed (Precitene Hiperproteico). MEASUREMENTS AND MAIN RESULTS: One hundred seventy-six (89 Impact patients, 87 control subjects) were eligible for intention-to-treat analysis. The mortality rate was reduced for the treatment group compared with the control group (17 of 89 vs. 28 of 87; p < .05). Bacteremias were reduced in the treatment group (7 of 89 vs. 19 of 87; p = .01) as well as the number of patients with more than one nosocomial infection (5 of 89 vs. 17 of 87; p = .01). The benefit in mortality rate for the treatment group was more pronounced for patients with APACHE II scores between 10 and 15 (1 of 26 vs. 8 of 29; p = .02). CONCLUSIONS: Immune-enhancing enteral nutrition resulted in a significant reduction in the mortality rate and infection rate in septic patients admitted to the ICU. These reductions were greater for patients with less severe illness.     

Total and ionized serum magnesium in critically ill patients

Objective To assess the alterations in total serum magnesium (tsMg) and ionized serum magnesium (Mg²⁺) and their association with prognosis in critically ill patients.Design and setting Prospective, cohort study in the intensive care unit (ICU) of a university teaching hospital.Patients Adult patients admitted to the ICU without previous factors influencing magnesium homeostasis were included during a 6-month period.Measurements and results One hundred forty four patients were included. Mean age was 60.6±15.4 years; mean APACHE II score was 12.6±6.9. Blood samples were collected in the first 24 h after ICU admission and again on the second, third, and last days of stay in the ICU. At ICU admission 52.5% had total hypomagnesemia and 13.5% total hypermagnesemia; with respect to the Mg²⁺ 9.7% showed ionized hypomagnesemia and 23.6% ionized hypermagnesemia. Patients who developed ionized hypermagnesemia had higher mortality than patients without ionized hypermagnesemia development (P=0.04). A moderate correlation between tsMg and Mg²⁺ concentrations was found; however, a number of patients with total hypomagnesemia (69–85% during the study) had ionized normomagnesemia. The measure of agreement between tsMg and Mg²⁺ levels was poor.Conclusions Magnesium alterations are frequently found in critically ill patients. The usually determined tsMg levels are not a reflection of Mg²⁺ levels. Development of ionized hypermagnesemia is associated with prognosis.     

Bedtime problems and night wakings in children

Bedtime problems and night wakings in children are extremely common, and the treatment literature demonstrates strong empirical support for behavioral interventions. Empirically validated interventions for bedtime problems and night wakings include extinction, graduated extinction, positive routines, and parental education. Most children respond to behavioral interventions, resulting not only in better sleep for the child, but also better sleep and improved daytime functioning for the entire family. This article reviews the presentation of bedtime problems and night wakings, empirically validated interventions, and challenges to treatment in both typically developing and special populations of children.     

A comprehensive review of the treatment of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is an uncommon but malignant cutaneous neuroendocrine carcinoma with a high incidence of local recurrence, regional lymph node metastases, and subsequent distant metastases. The etiology of MCC remains unknown. It usually occurs in sun-exposed areas in elderly people, many of whom have a history of other synchronous or metachronous sun-associated skin lesions. The outcome for most patients with MCC is generally poor. Surgery is the mainstay of treatment. The role of adjuvant therapy has been debated. However, data from recent development support a multimodality approach, including surgical excision of primary tumor with adequate margins and sentinel lymph node dissection followed by postoperative radiotherapy in most cases, as current choice of practice with better locoregional control and disease-free survival. Patients with regional nodal involvement or advanced disease should undergo nodal dissection followed by adjuvant radiotherapy and, perhaps, systemic platinum-based chemotherapy in most cases.     

Corticosteroids in the Management of Severe Coccidioidomycosis

Background

There is limited data suggesting that recovery from severe pulmonary infection with Coccidioides may be hastened by the addition of systemic corticosteroids.